60 Minutes for Docs: Preparing Psychiatrists for Health Reform

Transcription

1 60 Minutes for Docs: Preparing Psychiatrists for Health Reform John S. Kern MD Senior Medical Consultant, MTM Services Chief Medical Officer Regional Mental Health Center Merrillville, IN June 19, 2013

2 Much of this material drawn from my chapter in: Operationalizing Health Care Reform, David Lloyd, ed., National Council for Behavioral Health, 2013.

3 Overview > Impact of payment change > Working in teams > The primary care world > Scaling up a scarce resource > Off the hamster wheel > Why this is a good thing

4 Health Care Reform as it applies to psychiatry > The triple aim: Improving the patient experience of care. Improving the health of populations. Reducing the per capita cost of healthcare.

5 New Payment Models > Accountable Care Organizations > Patient-Centered Medical Homes > We fit perfectly in these

6 The Prominent Role of Primary Care The only thing you can do more of and save money report from the American College of Physicians

7 Why Collaborative Care is Crucial > Makes possible scaling up of psychiatric expertise > Improves access to care. > Improves primary care outcomes > Saves money.

8 Core Principles Of Effective Collaborative Care Person-Centered care teams providing Evidence-based treatment to a Defined population of patients utilizing a Measurement based treat to target approach Aims Center 2010

9 Missouri Chronic Care Improvement Program: Medicaid Cost Savings for 6,757 people > OFF TREND SAVINGS OF $25 million annually > Actual Pharmacy services decreased by $9.2 million annually or 23% > Actual General Hospital services decreased by $1.5 million or 6.8% > Actual Primary Care services increased by $774,000 or 21%

10 $ PMPM $1,600 $1,400 $1,200 $1,000 $800 $600 $400 $200 $- MO HealthNet Average Total Monthly Costs for CCIP Disease Eligible Population Mar-08 Feb-08 Jan-08 Dec-07 Nov-07 Oct-07 Sep-07 Aug-07 Jul-07 Jun-07 May-07 Apr-07 Mar-07 Feb-07 Jan-07 Dec-06 Nov-06 Oct-06 Sep-06 Aug-06 Jul-06 Jun-06 May-06 Apr-06 Mar-06 Feb-06 Jan-06 $1,283 PMPM $962 PMPM Actual CCIP Enrolled Eligible-Not Enrolled Linear (Actual) Average Total Monthly Costs for CCIP-enrolled participants were below projection. March 2008 demonstrates a $321 PMPM savings.

11 The Role of the Psychiatrist in Collaborative Models > Supporting and guiding mental health care. > Expanding inadequate access. > Supporting and guiding primary care to SMI population. > Playing role in primary health care models that require care management, management of MH problems, improvement of health care behaviors.

12 What collaborative models look like > IMPACT > TEAMcare

13 Collaborative Team Approach How does it look? PCP Core Program Patient Care Manager Consulting Psychiatrist Other Behavioral Health Clinicians Additional Clinic Resources Substance Treatment, Vocational Rehabilitation, Other Community Resources Outside Resources

14 Consulting Psychiatrist an Essential Part of this Model of Care > Clinical consultation and supervision of BHPs > Telephonic/ /text consultation to PCPs and BHPs curbsides > Track and oversee panels and clinical outcomes > Suggest treatment plan changes intensification of treatment in real time, treat to target > Refer to higher level of care if needed > Consultation notes based on discussion with BHP, chart review, direct evaluation > On site clinic visits scheduled or prn > Co-visits with PCPs and BHPs > Education > Insure adherence to the model, prevent regression to co-location

15 How does it look from 5 feet? Collaborative Care: The Graphic Novel

16 Stepped Care Treatment Model BH specialty short term tx BH specialty long term tx Psychiatric Inpatient tx Self- Management 1 o Care 1 Care + BHP Psychiatric consult (Face-to-face) Jim Rundell 2010

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18 What Does Good Care Look Like? [from Jeff Brenner] Accessible Responsive Personalized Community-based Integrated Holistic Examples PACE Program ACT Team Nurse Family Partnership Ryan White Clinic Health Quality Partners Does this sound familiar?

19 Early Lessons Learned [from Brenner] > Clinical model» Biggest obstacle is the delivery system itself, not the patients» Need to be in the community and accompany patients to appointments» Early life trauma is a key variable» Many sub-type of patients within the outlier patients which require micro-targeting strategies» Need primary care that can pivot to the unique needs of the patients» Need data driven screening and targeting» You guys figured this out already Assertive Community Treatment

20 Primary Care in Behavioral Health > Horrible health outcomes well-documented elsewhere. > Does anyone have a client over 50? > We need to make dent in premature mortality

21 What is the Psychiatrist Role in Improving Heath Status? Minimizing metabolic effects of psychotropic medications Screening for cardiometabolic risk factors Counseling for lifestyle issues Treating some basic medical conditions Leading teams PBHCI project directors

22 Primary Behavioral Health Care Initiative Primary Behavioral Health Care Initiative (PBHCI) SAMHSA grant demonstration projects to improve physical health status in SMI 93 grantees, beginning 2009 Target audience Quadrant 4: Both high physical and high mental health risk. Better coordinate and integrate primary and behavioral health care resulting in: Improved access to primary care services Improved prevention, early identification and Intervention to reduce the incidence of serious physical illnesses, including chronic disease Increased availability of integrated, holistic care for physical and behavioral disorders Better overall health status of clients 21

23 Roles for Psychiatrists in managing chronic illnesses in CMHC settings Co-Management Manage with Primary Care Consult Comprehensive Management Each provider has their own caseload PCP manages all medical problems Psychiatrist manages all mental health problems Work together to reenforce treatment plans Psychiatrist works with a care manager Manages a caseload of patients for BOTH mental health and basic medical health concerns using protocols from PCP PCP available for consultation and stepped care as needed Typically dually trained psychiatrist Provider manages both medical and mental health problems Limited number of providers have this expertise All psychiatrists are responsible for not making people sicker.

24 An example: a Hypertension Algorithm 1 st LINE: Thiazide Diuretics Unless have CHF, DM, Chronic Kidney Dz HCTZ mg, 25 mg, 50 mg (max) Chlorthalidone 25 mg (max) QD dosing, Check electrolytes 4-6 weeks, then q 3 mos, then annually Add second agent if partial response $ 4 list - both 2 nd LINE: ACE Inhibitors 1 st line for above dx Lisinopril 5mg, 10 mg Enalapril 2.5mg, 5 mg, 10 mg, 20 mg Start at 5-10 mg/day and titrate up to as much 40 mg per day. Check electrolytes 8-10 weeks. Stop if CR > 2.5 Once a day, dry cough, elev CR, angiodema, facial swelling, do not use in pregnancy $ 4 list 3 rd LINE: Calcium Channel Blockers Amlopidine 2.5 mg, 5 mg, 10 mg (max) Nifedipine LA 30 mg, 60 mg, (max 90 mg ) Very potent, if adding as 3 rd agent call PCP first! can cause peripheral edema 4 th LINE: Beta Blockers Metoprolol succinate (XL) 25, 50, 100, 200 (200 mg max) Once a day, Do not give if Pulse <55, mg/day usual, can go to max 200 mg ** Remember BP 139/89 is fine for all patients Adjust meds q 2 weeks, follow q 3-6 mos once stable If K+ falls below nl and BP responding, add 10 meq K+ up to total dose 20 mg Courtesy Lori Raney MD

25 Druss - Psychiatrist as public health practitioner > Psychiatrist as behaviorist - MI, focus on health behaviors. > Psychiatrist as advocate impacting funding > Psychiatrist as Internist, especially for common treatments of CV disorders: HTN, lipids, DM > Psychiatrist as Leader - especially in the public MH sector.» CMHC medical directors have unique knowledge about complex pts, need skills and willingness to take on these roles.

26 > Never enough psychiatrists Scalability of psychiatric expertise

27 We will never have enough mental health specialists?

28 Psychiatry Workforce Population Served Population / FTE Psychiatrist Seattle 7,000 6 min Psychiatrist time available per week for each patient in need Rural / Urban Underserved in US 25, min *Assuming psychiatrist sees patients for 33 hours / week and 5 % of population need mental health services

29 Psychiatrist Quality of Work Life > Hamster wheel > Focus of work overly narrowed to psychopharmacology > Attracting talented young doctors

30 What do CBHO s need to do to prepare for collaborative models? > Get educated and practice > Train your staff in new models > Engage primary care partners > Engage funders, ACO s, etc. > Participate in getting funding in place: e.g., health homes.

31 > AIMS Center > CIHS > U Mass > Cherokee > University of Michigan Training staff in collaborative models

32 A New Skill Set for Psychiatrists Population Focus: Learn how benchmarking and metrics can be used to establish priorities for care delivery, identify high utilizers Benchmarking: How do we compare with others? Metrics: Are we following established guidelines? Registries: What disorders do we prioritize given our data? Diabetes? Hypertension? Determine training needs Claims data: High utilizers? Who isn t taking their meds? Data Driven: Follow progress in registries to optimize treatment course things that are measured improve Enhance knowledge of other medical conditions - Reacquaint ourselves with our latent skills in treating other medical disorders Shared accountability for outcomes Lead Teams trained in both worlds unique position 31

33 Summary in case you slept through the whole webinar 1. Teams 2. Value to the larger medical world

34 Questions